1. Anaphylaxis Dr. S. Parthasarathy MD., DA., DNB(anaes), MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi medical college and research institute, puducherry – India

2. Definition Anaphylaxis is an acute reaction leading to severe physiologic derangements of multiple systems. Follows the administration of allergen to a sensitized individual True anaphylaxis denotes an IgE antibody- mediated reaction Non IgE antibody- mediated reaction resembling anaphylaxis is anaphylactoid reaction

3. Why should there be a name like that ?? Inj TT – protects further tetanus disease This is prophylaxis Portier and Richet in 1902 reported that the second injection of sea anemone extract into dogs resulted in a fatal systemic reaction Iron inj. -- First time – ok – on second injection It is fatal = antagonistic of prophylaxis – anaphylaxis

6. Histamine release but not anaphylaxis Morphine Skin alone ?? Atracurium Skin and lungs also ??

7. Why are some of us destined for a life of allergy and others not? Low grade responders Ige antibodies less with interferons High grade responders Ige antibodies more with cytokines

8. Incidence in anaesthesia It varies 2 in 10,000 to 4.5 in 10000 In france single institution study – 16 in 10000

9. Clinical manifestations of anaphylaxis IV antigen ----= starts in 5 minutes Other routes like oral Slower and less rapid progression

10. Clinical tips – may not be severe Already asthmatic - Already on beta blockers Ill health

11. Grades of clinical signs Grade I presence of cutaneous signs; (10%) Grade II as presence of measurable but not life- threatening symptoms including cutaneous effects, arterial hypotension(22%) Grade III as presence of a life-threatening reaction, collapse, severe bronchospasm, arrhythmias,(66 %) Grade IV cardiac and/or respiratory arrest (4%)

12. Anaesthesia symptoms -- Cutaneous, respiratory, CVS, GI Single system involvement – overlooked During general and regional anesthesia or during deep sedation, cardiovascular signs predominate Epidural hypotension –give colloids – anaphylaxis to colloids --- Gloom ??

13. Anaphylaxis under anaesthesia is not routine — most common triggers It is not community anaphylaxis like – Food stuff Bee sting Wasps Snake bites What happens in anaesthesia ?? Unconscious !!

14. Anaesthesia – confounding During general anaesthesia, early symptoms of anaphylaxis such as tongue swelling, itch, breathing difficulty and wheeze Skin lesions under the drapes

15. Differential diagnosis In a conscious patient, anaphylaxis is most easily confused with a vasovagal reaction, which may occur when a patient collapses after an injection or painful procedure But there is a bradycardia in a vasovagal reaction

16. Differential diagnosis cold urticaria (especially if generalized), idiopathic urticaria, carcinoid tumors, and systemic mastocytosis. Symptom based DD

17. Who are prone ?? Females Previous anaphylaxis patients with spina bifida or allergy to some fruit- latex allergy IgA deficiency- blood and colloids

18. TREATMENT OF ANAPHYLAXIS Initial Secondary

19. Initial Remove the offender Venous tourniquet Airway maintenance with 100% oxygen laryngeal edema -- aerosolized epinephrine epinephrine by nebulizer (8–15 drops of 2.25% epinephrine in 2 mL normal saline) Large bore IV lines intravascular volume should be maintained with administration of isotonic crystalloid

20. Rapid infusion of an initial bolus of 1–2 L intravenous fluid initially (20 mL/kg initially in children) before reassessment. Adults may require 2–5 L.

21. Epinephrine

22. severe hypotension or airway obstruction 0.1-mL (100μ g of a 1:1000 dilution) increments of epinephrine should be given intravenously, usually not exceeding 0.5 mg total. Beware – halothane, stroke, infarction

23. NO IV access 0.3 mL of 1:1000 epinephrine can be given subcutaneously or intramuscularly, or 10 mL of 1:10,000 epinephrine can be administered through the endotracheal tube. Hypotension and bronchospasm Norad, dopamine infusions to follow

24. Secondary Antihistaminics – diphenhydramine Ranitidine 1 mg/ kg Steroids : hydrocortisone- 5 mg/kg (up to 200 mg initial dose) and then 2.5 mg/kg every 6 hours- methylprednisolone 1 mg/ kg initially and every 6 hours IV aminophylline infusion Bicarbonate – controversial

25. Refractory hypotension Glucagon may be administered as a 1–5 mg (20–30 μg/kg in children, maximum 1 mg) dose over 5 min followed by an infusion of 5– 15 μg/ min Recently – vasopressin

26. Diagnosis Mast cell tryptase Postmortem collection of samples for assay is also possible 2 tubes 5 – 10 ml – 6 hours gap within 48 hours means 4 deg Or – 20 deg.

27. Diagnosis Immunodiagnostic Tests Intradermal skin tests still are the most readily available and generally useful diagnostic tests for drug allergy. Total Serum IgE Levels Assays to Measure Complement Activation Blood and urine assay of histamine mediators Radioallergosorbent Testing

28. Perioperative environment

29. Neuromuscular Blocking Agents Suxamethonium Pancuronium, atracurium, alcuronium

30. Opioids Histamine release is common Morphine and pethidine anaphylaxis are rare NSAIDs Penicillin and betalactams, cephalosporins, septran Skin test is almost foolproof to avoid it.

31. Radiocontrast Urticaria, angioedema, wheezing, dyspnea, hypotension, or death occurs in 2–3% of patients receiving intravenous or intraarterial infusions. Oral prednisolone, with AH prior to IV contrast

32. Local anaesthetics Genuine allergic reactions to local anaesthetic agents are extremely rare Preservatives

33. Colloids Clinical anaphylaxis to all groups of colloids is possible, including gelatins (such as Haemaccel® and Gelofusine®), albumin, dextrans and starches. Dextrans proved

34. Methylmethacrylate Episodes of hypotension, tachycardia reported Whether anaphylaxis – proved ?? Protamine Diabetics – use insulin protamine

35. Induction agents Propofol was originally formulated in a vehicle containing Cremophor® EL but was reformulated as a lipid emulsion following reports of severe allergic reactions. Egg allergy ?? Thiopentone reported, methohexital – no

36. Transfusion-Related Anaphylaxis In GA Refractory unexplained hypotension Haematuria

37. Natural Rubber Latex Children with spina bifida and urogenital anomalies Gloves Ambu bag Reservoir bags Masks Latex injection ports Tourniquets Blood pressure cuffs

38. Summary Definition,mechanism, incidence Clinical manifestations Differential diagnosis Lab Treatment Anaesthetic factors and tips

39. Thank you all